Provider Demographics
NPI:1669122396
Name:SOSA, MIRACLE
Entity type:Individual
Prefix:
First Name:MIRACLE
Middle Name:
Last Name:SOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 BLACKFOOT
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79928-6019
Mailing Address - Country:US
Mailing Address - Phone:915-255-6120
Mailing Address - Fax:
Practice Address - Street 1:6028 SURETY DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2018
Practice Address - Country:US
Practice Address - Phone:915-544-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106602104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker